Chronic kidney disease (CKD) is associated with an increased risk of cardiac events and death; however, underuse of guideline-recommended therapies is widespread. The extent to which hospital performance affects the care of patients with CKD and non-ST-segment elevation acute coronary syndromes (NSTE ACSs) is unknown.Observational cohort.81,374 patients with NSTE ACSs treated at 327 US hospitals.Hospital performance, measured by quartiles of composite adherence to American Heart Association class I guidelines for therapy acutely (aspirin, beta-blockers, clopidogrel, heparin, and glycoprotein IIb/IIIa inhibitors) and at discharge (aspirin, clopidogrel, angiotensin-converting enzyme inhibitors, and lipid-lowering agents) in eligible patients.Use of each American Heart Association class I acute and discharge therapy stratified by continuous estimated glomerular filtration rate (eGFR). Multivariable models were adjusted for demographics, clinical factors, and hospital features.Better-performing hospitals had lower prescribing rates for most therapies (5 of 9) with lower levels of kidney function, whereas lower-performing hospitals were more likely to have similar prescribing rates across the eGFR spectrum, suggesting that prescribing patterns at these hospitals were insensitive to differences in eGFR.Observational design, selection bias of study cohort.Patients with lower levels of kidney function admitted with NSTE ACSs are less likely to receive evidence-based therapies. Treatment disparities related to CKD are most evident at top-performing hospitals.